The challenging road to universal health coverage
Authors: Simiao Chen, Zhong Cao, Zhuoran Wang, Chen Wang
Journal: The Lancet Global Health (2023)

Universal health coverage (UHC) has evolved from a metric of health-care access to a foundational belief in health as a human right.1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1251) Google Scholar Adopted within the Sustainable Development Goals (SDGs), UHC represents the aspiration that people have unimpeded access to essential health services without the strain of personal financial hardship. Although advancements have been made towards realising this vision, the pace of progress has decelerated since 2015.2WHOWorld health statistics 2023: monitoring health for the SDGs, sustainable development goals.https://www.who.int/publications/i/item/9789240074323Date: 2023Date accessed: July 21, 2023Google Scholar Specifically, coverage of essential health services (SDG 3.8.1) increased by merely three index points, from 65 to 68, between 2015 and 2021 (coverage was 58 in 2010). The financial protection indicator, defined as the proportion of a country's population with large household expenditures on health relative to their total household expenditure (SDG 3.8.2), measures another crucial facet of UHC. The proportion of the global population allocating more than 10% of their household budget towards out-of-pocket health expenditures has risen at an average of 0·2 percentage points per year since 2015 to reach 13·5% in 2019, representing roughly one billion people who predominantly live in the Western Pacific region, South-East Asian region, and African region.2WHOWorld health statistics 2023: monitoring health for the SDGs, sustainable development goals.https://www.who.int/publications/i/item/9789240074323Date: 2023Date accessed: July 21, 2023Google Scholar Achieving UHC remains a challenging goal for several reasons. First, many low-income and middle-income countries do not have the necessary funding for UHC. The prioritisation of UHC requires strong political commitment, but some governments do not view health as a primary policy priority, or might be influenced by competing interests such as education, infrastructure, and defence. The investment in achieving these goals is severely inadequate, with an annual funding gap exceeding US$4 trillion.3Shulla K Leal-Filho W Achieving the UN Agenda 2030: overall actions for the successful implementation of the Sustainable Development Goals before and after the 2030 deadline.https://www.europarl.europa.eu/RegData/etudes/IDAN/2022/702576/EXPO_IDA(2022)702576_EN.pdfDate: 2023Date accessed: August 20, 2023Google Scholar Second, health insurance coverage is inequitable and inadequate. A recent study found that marginalised populations (such as women, people with less education, and people with low incomes) were less likely to have health insurance than non-marginalised populations, and only one in five people (20·3%) in low-income and middle-income countries had health insurance.4Chen S Geldsetzer P Chen Q et al.Health insurance coverage in low- and middle-income countries remains far from the goal of universal coverage.Health Aff (Millwood). 2022; 41: 1142-1152Crossref PubMed Scopus (4) Google Scholar Third, public health emergencies, such as the COVID-19 pandemic and climate change-related natural disasters, have amplified pre-existing health-care system vulnerabilities. Of 125 countries surveyed in the fourth round of WHO's Global Pulse survey on the continuity of essential health care, 84% reported disruptions in at least one crucial health care due to the pandemic from November, 2022 to January, 2023.5WHOFourth round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November 2022–January 2023.https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2023.1Date: 2023Date accessed: July 21, 2023Google Scholar Annie Haakenstad and colleagues6Haakenstad A Bintz C Knight M et al.Catastrophic health expenditure during the COVID-19 pandemic in five countries: a time-series analysis.Lancet Glob Health. 2023; 11: e1629-e1639Google Scholar assessed financial hardship due to health-care use and costs during the COVID-19 pandemic across multiple countries. Specifically, this pioneering study examined trends in rates of catastrophic health expenditure and associated drivers in Belarus, Mexico, Peru, Russia, and Vietnam. They found that in three of the five countries examined, health systems in 2020 failed to guard against financial risks or ensure health-care access, highlighting a failure in their basic functions. The study's findings address a gap in previous literature with respect to cross-country comparisons of catastrophic health expenditure during the COVID-19 pandemic. Such comparative studies are essential for understanding health system resilience and informing the development of effective future policies to combat household financial hardship. It is time for policy makers to change their mindsets regarding health expenditure as one of the most effective investments, instead of a burden or cost. Investing in health, through initiatives like expanding health insurance and providing essential health care, is a dual win for both societal progress and economic growth; it's not a zero-sum game where we gain in health at the cost of the economy, but rather a situation where both outcomes are simultaneously achieved.7Chen S Benefits of expanding health insurance coverage.https://healthaffairs.activehosted.com/index.php?action=social&chash=baed9f51d412c2514ee46a0942138ad6.6164&s=bad97c655476f96a390a72c05a742011Date: 2022Date accessed: July 21, 2023Google Scholar A healthier population will have increased human and physical capital relative to a less healthy one, which in turn enhances economic development.8Chen S Cao Z Prettner K et al.Estimates and projections of the global economic cost of 29 cancers in 204 countries and territories from 2020 to 2050.JAMA Oncol. 2023; 9: 465-472Crossref PubMed Scopus (14) Google Scholar, 9Chen S Kuhn M Prettner K et al.The global economic burden of chronic obstructive pulmonary disease for 204 countries and territories in 2020–50: a health-augmented macroeconomic modelling study.Lancet Glob Health. 2023; 11: e1183-e1193Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Moreover, underspending on health is a major and urgent issue in many countries, and policy makers should appropriately rebalance resources between total health expenditure and investments in other sectors (thereby improving macro-level efficiency in health expenditure). A recent study of macro-level efficiency in health expenditure found that allocating 14–16% of gross domestic product (GDP) to health expenditure would maximise lifetime population welfare in the countries studied. Notably, in 2020, China spent only 5·6% of its GDP on health, Russia spent 7·6%, and India spent 3·0%, all far less than the identified range of 14–16%. These countries and others should therefore substantially increase investment in health to improve population welfare.10Chen S Kuhn M Prettner K Bloom DE Wang C Macro-level efficiency of health expenditure: Estimates for 15 major economies.Soc Sci Med. 2021; 287114270Crossref PubMed Scopus (8) Google Scholar UHC embodies a global commitment to recognise health as a human right, which is pivotal for economic development, national security, social stability, social civilisation, and human wellbeing. The pursuit of UHC is not a burden or drain on the socioeconomic fabric, but rather an investment, serving as a vital pathway to achieving a people-centred and sustainable development. Health policy makers should align with this perspective by emphasising health-care coverage, quality, and financial protection, and ensuring the existence of robust health systems that remain resilient even in the face of public health emergencies. We declare no competing interests. Catastrophic health expenditure during the COVID-19 pandemic in five countries: a time-series analysisIn three of the five countries studied, health systems either did not protect people from the financial risks of health care or did not maintain health-care access in 2020, an indication of health systems failing to maintain basic functions. If the 2020 response to the COVID-19 pandemic accelerated shifts to private health-care use, policies to cover costs in that sector or motivate patients to return to the public sector are needed to maintain financial risk protection. Full-Text PDF Open Access